Clinical and Health Affairs
Improving Health Care Provision to Somali Refugee Women
By Lindsay Wissink, M.P.H., Rhonda Jones-Webb, Dr.P.H., Diana DuBois, M.I.A., M.P.H., Bea Krinke, Ph.D., M.P.H., R.D., and Qamar Ibrahim
ABSTRACT
A growing number of Somali refugees are calling Minnesota home. Health care providers need to understand how best to serve these newcomers, many of whom are accustomed to a very different health care system and have a variety of expectations when it comes to the care they receive and the way it’s delivered. This study sought to gain insight into the health practices and health care preferences of Somali refugee women living in the United States, as well as their experiences with the U.S. health care system. In focus group discussions, participants expressed their preference for seeing women physicians, distrust of interpreters, and willingness to follow their physician’s advice. They also shared stories about incidents during which they felt they had been the victims of stereotyping. Increasing the number of qualified translators and providing cultural competency training for clinic staff are recommended first steps for improving the provision of care to Somali refugee women.
More than 40,000 Somali refugees have been admitted to the United States since 1989. The majority have come to this country since 1992.1 The total number of Somalis living in the United States is estimated at 150,000, with the largest concentration residing in Minnesota.2-6
Delivering adequate health care to Somalis has been a challenge for the U.S. medical community for a number of reasons. One major reason is the fact that the health care systems in the two countries differ greatly. In Somalia, clinic-based health care is primarily run by the government and focuses on secondary and tertiary care; neither appointments nor insurance are required.7,8 In contrast, the U.S. health care system is run by a combination of public and private organizations, focuses on primary and preventive care, and requires appointments and insurance.7,8 Given these differences, some Somalis may not attach the same value to clinic-based preventive care or understand the importance of keeping appointments as Americans do.
Another reason for the challenge experienced by the medical community serving Somalis is that religious and cultural differences present barriers between Somali patients and their health care providers. For example, some Somali women believe that a woman should not show her skin to any man but her husband.9 A patient who follows this religious guideline may prefer a female rather than a male physician. Because many U.S. health care providers do not understand such beliefs and practices, Somali patients may not be receiving the best care possible.5,10-12
Only a handful of studies have focused exclusively on the health care experiences of Somalis, and most have focused on those of Somalis living outside the United States.9,13-15 The purpose of our study was to gain an understanding of the health practices and health care preferences of Somali refugee women in Minnesota and to learn about their experiences with the U.S. health care system. We chose to focus on Somali women because they have a strong influence on the health of their families.4,5 In Somali culture, women are typically dominant in the home, and because they are often the primary caregivers, they make important decisions about the health and well being of their children. Another goal of the study was to provide recommendations for improving health care delivery to Somali refugee women living in this country.
Methods
We used focus group discussions to gather information. Focus groups are particularly effective in determining people’s perceptions and feelings about issues and services.16 They are considered a nonthreatening way for refugees to express their concerns about their new country and to articulate their needs.17 Perhaps most important, a focus-group discussion is a culturally appropriate way of gathering information from Somali refugee women, given their strong tradition of verbal communication and high rates of illiteracy.14,18,19
We hired two Somali women to facilitate the focus groups and assist with translation, transcription, and analysis. The two facilitators were chosen because of their close connection to the Somali community and their ability to learn focus-group facilitation. Both were in their 30s, had at least an undergraduate degree, and were otherwise employed full time in outreach positions that placed them in daily contact with Somali women. Each facilitator attended two days of training on how to conduct focus groups and analyze responses.
We also asked the facilitators to recruit focus group participants because of their access to the community and their ability to help establish trust between the researchers and the study population. We asked them to select women from the Somali community who were 18 years of age or older and had at least 1 experience with a health care provider in Minnesota. In addition, we asked the facilitators to obtain a sample that was representative of the community and included women from various economic, social, and educational backgrounds, as well as women who had lived in the United States and Minnesota for varying lengths of time.
The mean age of the 27 women who participated in the focus groups was 46 years (range 22 to 74 years). More than half (55%) were married; of those who were married, 58% lived with their husbands. About 27% of the women had an undergraduate degree. On average, the women had lived in the United States for 5 years and in Minnesota for 4 years.
Participants were frequent users of clinic services. On average, the women reported visiting a clinic 46 times while living in Minnesota during the past 4 years. Almost half (46%) had visited a clinic less than 1 month ago, with an additional 23% visiting a clinic 2 to 6 months ago (Table 1).
We developed focus group questions based on information available in the literature and from informal interviews with members of the Somali community and health care providers who regularly serve Somalis in the Twin Cities. Every effort was made to ensure that the questions were culturally appropriate, were not offensive, yielded new information, and provided information that was useful to primary health care providers. The questions focused on health beliefs and practices, health care preferences, and perceptions of treatment by health care staff in Minnesota (Table 2). All questions were translated into Somali by the facilitators. In addition, we obtained basic demographic information from each participant.
Three focus groups were conducted between March 21 and March 26, 2002. The facilitators worked as a team and conducted each focus group entirely in Somali. We transcribed the audio recordings of the sessions. Then, we reviewed the transcripts to identify common themes. Each transcript was analyzed using qualitative analysis software.
We coded the responses to each question using previously identified themes as code titles. The software automatically linked identical codes within and between focus groups. Code frequencies were tallied, and direct quotes were sorted according to code title. The facilitators were asked to review findings for validity prior to writing up the results. They worked closely with the project staff to ensure consensus when interpreting results.
Results
Focus group responses were categorized according to 4 themes: 1) health practices; 2) health care preferences; 3) perceptions of health care providers, staff, and services; and 4) provider and staff attitudes.
Health Practices
Some of the Somali women were aware of the importance of preventive care, but others were not. Six of the 27 women said they go to a clinic annually for a check up and to stay informed about their health. Most of the women (n=19) indicated that they usually follow their health care provider’s advice. However, 6 of the 19 said that they may not follow their doctor’s advice if they did not like or agree with it and may seek a second opinion.
Despite the high frequency of clinic use by Somali women, health care providers in the Twin Cities have observed that they do not often return for follow-up appointments.20 Six women in this study said that they might not keep a follow-up appointment if they felt mistreated by the doctor or other clinic staff. Four indicated they were aware that they should call and cancel appointments but said that not speaking English was a barrier to doing so.
Health Care Preferences
Somali women in general prefer female physicians. When asked if they felt more comfortable seeing a male or female provider, 15 of the women said they prefer to see a female provider because she can better understand their health issues. These women also indicated that they would be willing to see a male physician if a female physician was unavailable. Two women quoted an old Somali proverb that illustrates their belief that the provider’s gender is irrelevant: “If you are in labor [or otherwise in a lot of pain], you forget about being shy and covering up for any kind of doctor.”
Twelve of the women indicated that they preferred to have someone else in the exam room with them when seeing a health care provider. Of those who wanted a companion in the room, 10 said they wanted a family member or friend with them for emotional support.
When asked how they felt about a male health care provider touching them outside the exam room (for example, shaking their hands, placing a hand on their shoulders, or patting their arms), 11 of the women said they did not mind it. However, there was some disagreement as to whether Islam allows a male health care provider to touch a woman who is not his wife. One woman explained, “The religion [Islam] accepts that male health providers will touch you. There is no real gender problem.” Three women, however, indicated that Islam prohibits any touching of a woman by a male, regardless of whether he is a health care provider.
Perceptions of Health Care Providers, Staff, and Services
Almost all of the women who participated in the focus groups shared positive comments about their providers. Nearly two-thirds (n=16) said they trust and respect their providers and appreciate the way they are treated. Seven indicated that trusting and respecting their provider was only one part of what helped them get better, and that there was a spiritual component at work as well. For example, one woman said, “You have to tell yourself that this person has the knowledge to help you and then believe in [God] that you will get better.”
Ten women expressed distrust for interpreters whom, they believed, were unqualified to translate in a medical setting. One woman said, “Half of the translators aren’t really directly explaining what the patient says. They may not have medical knowledge and so can’t explain what the problem is. If translators are translating someone else’s problem, they should be qualified to translate in a medical setting.”
In terms of quality of service, 13 women expressed concerns about medications they were provided. In general, the women felt that the medications did not always make them feel better and, in some instances, made them feel worse. Five women expressed frustration with the time it takes to get an appointment and, once at the clinic, to be seen by the doctor.
Provider and Staff Attitudes
Although the women were generally pleased with their providers, 22 shared experiences of being stereotyped by clinic staff. A common experience mentioned by 6 of the women was that clinic workers assumed that patients did not speak English if they were wearing a Hijab (the cloth head/body covering that Muslim women wear). One woman said, “I had an appointment with an ophthalmologist, and they made me wait for 45 minutes. I asked what was taking so long, and they said they were waiting for a translator. I said, ‘You guys didn’t even ask me if I needed a translator, and I don’t.’ I thought that was stereotyping.” Five of the women said their experiences with stereotyping often occurred in the clinic’s reception area. Four indicated that nurses regularly exhibit these behaviors.
Discussion
The Somali refugee women in our study were willing to comply with physicians’ recommendations as long as they agreed with them, but they would get a second opinion when they disagreed. They also indicated that they may base their decisions to comply with their physicians’ recommendations on their past experiences with their doctors. One reason many women cited for not keeping follow-up appointments was mistreatment by the doctor or other clinic staff in the past. It is worth noting that many women, regardless of their race or ethnicity, may base their decision to follow a physician’s advice and return for a follow-up appointment on their prior experiences with the physician and clinic.
It was not surprising that Somali women preferred to see a female rather than a male physician. Many American women also prefer seeing a female physician because they believe that female physicians better understand their health concerns.21-23 Somali women who preferred to have someone accompany them in the exam room may do so for emotional support, as the study participants indicated, or because of a lack of interpreters in many medical settings or a distrust of interpreters.
Somali women’s perceptions of stereotyping by clinic staff have not been reported previously in the published literature.9,13-15 Given the recent arrival of Somali refugees to Minnesota, clinic staff may have limited knowledge of and experience working with this population and may rely on stereotypes when interacting with Somali women. Stereotyping can influence judgments about the kind of care different women want, need, and deserve and, therefore, interfere with clinic services. It should not be tolerated in the clinic setting.24,25
Conclusion
Certain cultural and social factors may act as barriers to providing quality primary care to Somali refugee women. Providers working with Somali and other refugee populations may wish to give greater attention to some of the social and cultural barriers observed in this study. Two of the most salient barriers reported by the women in our study were stereotyping by clinic staff and language. Thus, increasing the number of qualified interpreters and providing cultural competency training for clinic staff may be important first steps toward improving care provided to Somali refugee women. If health care service delivery to Somali women improves, so may their utilization of health care services and, consequently, their quality of life and that of their family members. MM
Recommendations for Primary Health Care Providers
The following recommendations for health care providers and staff who work with Somali women are based on the findings of this study.
For all health care staff
• Avoid stereotyping. Respect each Somali woman’s individuality by learning about her personal beliefs and preferences about health and health care.
• Understand that many Somali women may prefer to see female rather than male health care providers. Some women may feel more comfortable with a female provider; others may prefer a woman provider for religious reasons.
• Be aware that a Somali woman may want to bring one or more people into the exam room with her.
• If you are a man, wait for a Somali woman to offer her hand before you initiate a handshake. If she does not offer her hand, do not touch her except for clinical touch during the exam. Alternatively, ask a Somali woman first if it is all right to shake her hand, and ask her how comfortable she is with different kinds of touch.
• Try to have female interpreters available who are qualified to interpret in a medical setting and are credible and trusted by the Somali community.
• Provide cultural competency training for all clinic staff, particularly those who have initial contact with Somali patients.
For physicians and nurses
• Know that some Somali women already understand the concept of preventive care, including the importance of having annual check ups.
• Acknowledge the importance of religious beliefs to a Somali woman. Understand that your treatments will probably be supplemental to this belief system.
The authors would like to thank Safia Omar and Fadumo Abdi for their hard work throughout each phase of the project and for their valuable insights into Somali culture. We would also like to thank Minnesota International Health Volunteers for their direct supervision and Leadership, Empowerment, and Development Group for their collaboration on this project. This study was supported by grants from the International Rescue Committee and the University of Minnesota School of Public Health, Division of Epidemiology.
Lindsay Wissink is a nutrition counselor and breastfeeding coordinator for WIC in Portland, Maine. Rhonda Jones-Webb is an associate professor at the University of Minnesota. Diana DuBois is executive director of Minnesota International Health Volunteers. Bea Krinke is an instructor at the University of Minnesota. Qamar Ibrahim is executive director of Leadership, Empowerment, and Development Group.
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